Intro: It's Your Health Radio, a special podcast series presented by Henry Mayo Newhall Hospital. Here's Melanie Cole.

Melanie Cole, MS (Host): If your doctor recommends a prostatectomy, but you're concerned about the side effects, specifically erectile dysfunction, stay tuned because we're here to discuss the treatment options navigating erectile dysfunction post-prostatectomy. Welcome to It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. And joining us today is Dr. Kian Asanad. He's a urologist on staff at Henry Mayo Newhall Hospital and Keck Medicine of USC.

Dr. Asanad, it's such a pleasure to have you join us again today. Can you start by telling the listeners a little bit about what a prostatectomy even is and why somebody might need one?

Kian Asanad, MD: Absolutely. Thanks for the introduction, Melanie. It's so good to be back with you guys. So, prostate cancer is one of the most common cancers in men as men get older. And some forms of prostate cancer require treatment. And these are typically intermediate risk or high risk cancers. And treatment for prostate cancer can include surgery, which is standard of care, a robotic radical prostatectomy or radiotherapy.

And so, as a urologist, you know, urologists perform robotic radical prostatectomies, which means that we use a robot through small openings in the abdomen in a minimally invasive approach. And we surgically remove the prostate and the surrounding lymph nodes. The prostate sits at the bottom of the bladder, and it's between the bladder and the urethra, which is the urine tube. So when we perform a prostatectomy, we separate the prostate from its surrounding organs. So, we separate it from the bladder, we separate it from the urethra. We make sure that we stay away from the rectum, which sits below the prostate. And then, we have to separate the prostate with the nerve fibers. So, the nerves that are responsible for erectile function are intimately involved with the prostate. And using nerve-sparing techniques, we could preserve with complete bilateral nerve-sparing approaches for select patients to help optimize their sexual quality of life after surgery. Once the prostate's removed, we reconnect the bladder to the urethra, the urine tube with sutures and stitches that dissolve on their own. And men have a catheter for typically about a week to let things heal.

Melanie Cole, MS: Thanks so much, Dr. Asanad, for that explanation. Now, as you were talking about sparing nerves and you're going in there robotically and it's minimally invasive for the most part, do we know what causes some of these side effects and complications like erectile dysfunction after that kind of surgery?

Kian Asanad, MD: While we can preserve the nerves bilaterally on both sides, in the majority of patients and in many patients, sometimes it's not a good idea, right? And that just depends on the patient's disease status. So, if a patient has a high risk tumor, sometimes they could be bulging out of the prostate, right? And we don't want to leave cancer behind and try to preserve nerves. We're trying to find a balance between making patients cured of their cancer and optimize their sexual quality of life. So, sometimes on one side, potentially, we have to remove some of the nerves in order to remove the entire cancer on that side, for example.

But there's many other things that play a role in terms of erectile function recovery after surgery, right? So, we look at things like their baseline erectile function. So if their baseline erectile function is not great, it's not going to get better after surgery, it'll be the same or it'll get worse. So, I think that realization with patients is also very important.

Melanie Cole, MS: So, it's very important, Dr. Asanad, that you discuss all of these options with patients. When you're talking to them about that, how do you let them know everything you just said? Because I would imagine men specifically don't even want to see a urologist in the first place; and in the second place, it's very hard to hear these kinds of things.

Kian Asanad, MD: Of course, I mean, so many patients haven't seen a physician in a long time, or maybe they have a primary care doctor. The PSA is elevated, which is the blood test for prostate cancer screening. They'll be referred to a urologist for next steps, such as myself or another prostate cancer expert who will perform a prostate biopsy and determine if treatment of prostate cancer is warranted if present. And sometimes it requires a few office visits to talk about all these sorts of issues, right? So, urologists perform surgery that can have a significant impact on quality of life. So while we remove cancers from a prostate standpoint, it can cause issues such as erectile dysfunction after surgery; male stress incontinence, men will leak urine after surgery, that's very common. The majority of men regain their continence.

But yeah, there's a lot to discuss in a single office visit. Sometimes I'll have patients come back two weeks later, they'll think about things, learn a little bit more about the surgery, read about it, give them some resources. Many patients, while encouraged to see a radiation oncologist as well and see a consultation for the treatment of radiotherapy, that has their own kind of risks and benefits slightly different than a radical prostatectomy, and we really encourage patients to make an informed decision.

Melanie Cole, MS: Well, that makes so much sense. And while in another podcast we can talk about some of those complications with the adjuvant treatments, today, we're talking mainly about the surgery, how soon after a surgery like this would these kind of symptoms appear? Is this something that can take weeks to develop? And if nerves were a little bit traumatized during the surgery, nerves can take a long time to heal. So, tell us a little bit about what happens after surgery and how soon they might notice these things.

Kian Asanad, MD: Absolutely. So, I'll typically see men even before prostatectomy, if they're referred by my colleagues, for prehabilitation and postoperative penile rehabilitation. So, I'll start men on a Medicine such as tadalafil or Cialis to take daily. Even prior to surgery, which helps improve blood flow to the penis as a prehab, as well as penile rehab after surgery. Once the catheter comes out, typically five to seven days after surgery, they'll resume the medicine for the first few months after surgery to help improve erectile function recovery. And these are kind of immediate things. I mean, many men in the initial couple weeks to months after the surgery, you know, they're just focusing on many things from recovering from surgery in general, right? There's incisions of the abdomen, they're leaking urine, they're doing pelvic floor physical therapy to regain their continence. And at the same time, we start them on medical therapy, which has been shown to help improve erectile function.

As you mentioned, spontaneous erectile recovery can take one to two years after surgery, right? Even though nerves can be completely preserved around the prostate on both sides, the stretching of the nerves and the separation of the prostate can cause neuropraxia, meaning the nerves can fall asleep, if you will. That can take time for spontaneous improvement. And while we don't want to wait one to two years for that data to happen, we want to optimize things so patients can exercise their penis and optimize the health of the penis through things like medications, potentially injections, other vacuum pumps that we can integrate.

Melanie Cole, MS: And would you start those things pretty soon after? I mean, as you said, and nerves take a long time. And then, there is recovery time after surgery and maybe they're dealing with those adjuvant cancer therapy. Would you start erectile dysfunction treatment pretty quickly after that? Do you have to wait a while? I mean, you mentioned pumps, there's medication, there's all of these things. How soon are you willing to look at those things to try and help them out?

Kian Asanad, MD: Absolutely. So, I'll see patients typically two months after surgery, two to three months while they're continuing the Cialis 5 milligram or 10 milligram daily dose. And I want to see how things are recovering from an erectile function standpoint. And my goal is for them to obtain a penetrative quality erection. They're getting some fullness and blood for the penis, that's great. But to really exercise the penis, we want the patients to obtain a penetrative quality erection. So, I'll see them pretty soon after surgery, especially for men where erectile function recovery is very important. For some men, it's not as important. They don't want to be aggressive about it. That's totally fine. But for the men who do, I'll see them at two to three months. If there's no penetrative quality erection at that time, we'll try to maximize the oral therapy. I'll add Viagra typically, a 100 milligrams as a booster dose two to three times per week to really maximize blood flow to the penis from an oral standpoint. I'll see the patients typically two months thereafter. At this point, we're about four to five months after surgery. If there's still no erectile function, penetrative quality, resulting in intimacy, then at this point, many of the men, the leakage has resolved. If men are leaking, it's hard to be intimate while you're, you know, leaking. That's not a fun situation to be in. The leakage has resolved. Now, we could really focus on optimizing the erections.

For men who want to escalate efforts to the next step, I'll get them in the office and perform a penile injection. So, one of the treatment options a little bit more involved includes an injection into the penis, typically 10 to 15 minutes before intimacy with a medicine to induce an erection. And these are really strong medications that can induce an erection. We typically start at a low dose as a safe dose to try to understand the anatomy in terms of blood flow into the penis and blood flow out. In my practice, I'll also typically integrate an ultrasound of the penis, which helps identify objective numbers, like what's the blood flow in looking like? Are the patients able to maintain that blood flow? Are things like venous leak or veno-occlusive disease occurring, causing an inability to maintain an erection? And we'll get them on a pathway of intracavernosal or penile injections for the next few months, if that's something they'd like to do.

On the other side, there's some other options that I want to review, right? So, there are a few different options for erectile function recovery and management. So, there are vacuum pumps known as vacuum erection devices, or VED. It's probably the most cumbersome approach. I don't use it a lot in practice. It's a kind of a long hollow plastic tube that's placed on the outside of the penis that performs a suction at either electrical or mechanical. It helps improve blood flow to the penis, and some patients may place a plastic ring at the base of the penis to help maintain the erection. As you can imagine, it's not the most sexy of options when trying to be intimate with your partner.

But what I use it for in my practice, which has been shown to be most effective, is maintaining length of the penis, right? So if men haven't had an erection for six to 12 months after surgery, the penis shrinks. It can atrophy. That's a real thing. If men can lose length, they can lose girth of the penis. Vacuum erection devices have been studied and shown that if you apply a vacuum pump for 10 minutes a day for six months, these men will preserve the length of the penis after a prostatectomy, as well as maybe potentially improve length for a few centimeters. So for men who are noticing loss of length or are really worried by that, I'll integrate a vacuum erection device.

 The other option includes intraurethral gels or suppositories. So, these are medicines that are not injected through a needle, but it's a small syringe that includes a gel or maybe a small pellet, a suppository, that goes in the urine tube in the urethra to help improve blood flow directly to the penis to induce an erection. The reason these are not a common option is because they're not very effective. They sound really good in theory, but they're only about 30-40% effective to induce an erection. Common side effects include pain or burning when you urinate, or most commonly just, "Doc, it didn't do anything," right? Seventy percent of the time, it's not effective. So, most men want to try an option if they're paying for it through a compounding pharmacy, that's going to be effective. So, the most common treatment approaches are things like injections, penile injections that will teach patients how to do and find a good regimen. Patients at some point, typically at six months after surgery or longer, we can start to talk about a penile prosthesis or a penile implant.

Melanie Cole, MS: Wow, there's so many options. This is really interesting. And how far your field has come, what an exciting time. And while we're talking about all of these different tools in your toolbox, Dr. Asanad, what about research? Is there anything really exciting that's down the pike that we can think of in the next five to 10 years that you are very excited about for men that either have prostate cancer and have complications from other therapies, which we didn't get into those, but also if they've had a prostatectomy. Is there anything exciting that you can think of telling us?

Kian Asanad, MD: Yeah. So, I really, again, try to tailor it to the patient. Some men, they want to be very aggressive about their penile health and want to attack things from the forefront. And some men have very severe erectile dysfunction and not all treatments work for every patient. There is a new treatment option that's been studied for the past few years, known as shockwave therapy or low-intensity shockwave therapy. It's been studied primarily in men who do not have prostate cancer, have not had a prostatectomy. And it's kind of the closest thing we have to a cure for erectile dysfunction.

And what it is, it's a medical device. There's different types of shockwave options. The ones that are not shown to be effective are things like acoustic waves, GAINSWave or radial waves, but actual shock pulses of the penis can improve spontaneous erectile recovery. But the studies so far in the past two years that have been strong randomized trials published in the Journal of Urology and Journal of Sexual Medicine, look at predominantly men who are younger, who have mild-to-moderate erectile dysfunction, can see up to 30% improvement in spontaneous erectile recovery. And I think that hasn't been studied yet well in the post-prostatectomy space in terms of inducing spontaneous erectile recovery. So, that's something to look forward to on the horizon. I don't routinely recommend it because, unfortunately, it is an out-of-pocket cost. It can have high associated costs with it. It's typically not covered by insurance, although we're working on that. Some men don't want to go down that road, and it's more experimental based on the AUA and SMSNA guidelines currently. So, it's not a standard of care option compared to the tried and true methods we know, such as injections or surgery, those types of those sorts of things.

Melanie Cole, MS: Dr. Asanad, you mentioned penile implants. Can you tell us a little bit more about the penile prosthesis and what that involves for patients?

Kian Asanad, MD: Yeah. So, a penile prosthesis, also known as a penile implant, it's a mechanical device to help induce an erection. So, it's a inflatable device. It has three parts to it. There are two cylinders that sit on the inside of the penis. It's connected to a pump, a balloon or a reservoir that sits inside the pelvis. And when a man wants to have an erection, he pumps up the device, gets a 10 out of 10 erection, could be intimate with his partner, and then squeezes a button to bring the erection down. It's an outpatient procedure. It takes about an hour to place through typically a small three to four centimeter opening above the base of the penis. We can get all the parts through there. Most men go home the same day. You can't use the device for two to three weeks after surgery. Most men just need oral medicine for a few days. And then, as soon as two to three weeks after surgery, I'll see them in the office and teach them how to inflate and deflate the device. And again, this device is entirely on the inside of the body. There's nothing on the outside. It's totally concealed. Men feel a significant improvement in their self-confidence. There's significant spontaneity seen with couples with the penile implant, and it's been shown to have the highest satisfaction amongst the different treatment options after oral therapy in terms of erectile dysfunction.

Melanie Cole, MS: Dr. Asanad, you're just such a wealth of knowledge and a great educator. I just love having you on with us. As we wrap up, what would you like to tell men and their partners if they hear those dreaded words that they are diagnosed with prostate cancer and all of the different options that are out there when they get that diagnosis, but one of them is a prostatectomy and the complications that come with it? And you mentioned prehab and pelvic floor, which many people assume are just for women, but they're not. And as an exercise physiologist, I've worked with men on those pelvic floor therapies before prostatectomy, so I know that they can help to strengthen those muscles. But what do you tell them in preparation? What would you like the listeners to get out of this podcast today to give them some hope that there are all of these options that you've described here today?

Kian Asanad, MD: Take the time to review the different options. I want to shed light on a common misconception in that the different treatment options do not require failing one, moving to the next, failing the next, moving to the next. The first step is oral therapy. In my practice, men should start an oral medicine before going through some of the more invasive options. But I think once oral therapy has not been shown to be effective, men want to be intimate with their partners. They want a reliable erection. Really, the two most common options are injections or surgery.

And I want to talk about the penile implant for a few minutes because I think traditionally we thought of it as like the end-of-the-road treatment option or surgery for an erection, right? It sounded crazy, but now we know that it has the highest satisfaction amongst patients and their partners in terms of treatment for erectile dysfunction. And the thing we know is that most men who end up receiving a penile prosthesis could be two to three years after prostatectomy. They've lost a lot of length of the penis. They say, "Doc, my penis is shorter. It's skinnier. I haven't had an erection in one to two years. I haven't been intimate with my wife. I want to revitalize that." Then, at that point, we're talking about a penile implant, which is typically an outpatient surgery. And men are really happy. The men who maybe have some dissatisfaction is because they've lost length and anatomy of the penis and they remember their erection five to 10 years ago, and it's not the same now. The device does not give you the erectile quality or the penile anatomy that you had a few years ago. It's the anatomy you have today when I meet you. So when they compare the two treatment options, the penile prosthesis has been shown to have the highest satisfaction, and it allows for spontaneity with couples. Injections work well for most patients, but only about 50-60% of patients after a year of injections continue to inject because this has to do with things like pain, lack of reliability, lack of spontaneity, most importantly, right? You got to inject the penis with a medicine 15 minutes before intimacy, it's not the most spontaneous option.

I really try to give all options to the patient and counsel them that a penile implant is a great option. I typically don't perform it within the first six months. But I think if patients want to be aggressive about getting their erections back and their oral medicine's not effective, and they don't want to poke a needle into their penis, I think a penile implant makes sense. It's a great option. I do a lot of that sort of work, so I'm very passionate about it. It should be done at a center of excellence and so I think that'd be the take home point.

Ultimately, there's lots of different treatment options for erectile dysfunction after prostatectomy, which is the great news. ED will occur, most men will have ED, some sort of ED after prostatectomy. The time for nerve recovery to occur can take 18 months to two years. But we don't want to wait that long. And I think being aggressive about that through prehab, penile rehab, oral medicines, and then discussing injections versus surgery as soon as six months is a very reasonable approach.

Melanie Cole, MS: Thank you so much, Dr. Asanad, what an expert you are,. And thank you so much for joining us and sharing that expertise with the people listening today because it's so important that we hear from someone such as yourself that does these on a daily basis, and kind of demystifies it for us. So, thank you again for joining us. And you can visit the Henry Mayo Newhall free online library and get so much information there at library.henrymayo.com. That concludes this episode of It's Your Health Radio with Henry Mayo Hospital. I'm Melanie Cole. Thanks so much for joining us today.